The US health care system is one of the most complex structures in the world: it’s an historic amalgamation of intermediaries, conditions, and conventionalities

This article seeks to explain the intricacies of the American health care system, its use of quality measures and establish how these measures affect the health care delivery process.

A brief history of quality measurement

Quality management started in the early 1900s as a statistical sampling method used to ensure that products met standards. Sampling evolved to a broader system view, referred to as quality assurance.

Two of history’s most prominent leaders, Joseph Juran and Edward Deming, advocated for this systems view, and went further, stating that is a CEO’s imperative to ensure quality via a method called total quality management (TQM) In their later years, their approaches seeped beyond manufacturing into service industries.

Compared to other industries, such as manufacturing and aviation, health care is still in its infancy as it relates to its sophistication in measuring quality.

Although a history of health care quality is beyond the scope of this article, it is reasonable to say that prior to 2010’s health care reform, there were limited national standards that measured quality across the insurer, provider, and physician levels simultaneously.

What types of measurements should we be concerned about?

According to the official definition suggested by The Institute of Medicine, health care quality can be described as the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Health Care quality measures should measure clinical quality (doing the right thing, at the right time, to the right patient) and patient experience.

Measuring clinical quality and patient experience requires a collection of a variety of measurements. The Institute of Medicine further elaborates their point and states that, for health care to live up to the established quality standards, it must also be characterized by the following domains or properties:

Safety. Generally, this refers to the actual or potential bodily harm caused in the process of receiving care and the extent thereof. A numerical value can be put on patient safety by assessing the percentage of health care beneficiaries on persistent prescription medications who are being continuously monitored and the percentage of elderly beneficiaries diagnosed with certain chronic conditions receiving contraindicated medications.

Effectiveness. This is associated with the process of delivering appropriate health care solutions to the patients and achieving outcomes as supported by scientific evidence. The effectiveness of health care can be delineated by measuring the percentage of health plan beneficiaries receiving recommended care (either an evaluation or treatment) for a specific health condition. Modern health care quality measures predominantly focus on diabetes, cardiovascular disease, musculoskeletal conditions, respiratory conditions, or behavioral health. Health care effectiveness is also linked to the percentage of health care beneficiaries receiving preventive care such as immunizations, flu shots, and screenings.

Efficiency. This factor refers to the process of maximizing the utilization of the health care resources available to any given health care provider.

Equity. This property describes the importance of health care providers delivering care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care. The goal is to ensure there are not any discrimination in the experience heath care beneficiaries receive regardless of their social status, nationality, religion, race, etc.

Preparedness. Relates to the capacity for providing high-quality care and service, e.g. percentage of board-certified physicians.

Patient centeredness. This measures the ability to meet patients’ needs and preferences and provide adequate support, both mental and physical. It can be quantified by considering the rates of health care beneficiaries’ complaints or appeals over coverage decisions.

Timeliness. This relates to the health care provider’s ability to provide care when needed, while also minimizing real delays and eradicating the causes of potential delays.

The Centers for Medicare & Medicaid Services (CMS) website also expresses the value of measurement in tracking policy outcomes and focusing on improvement initiatives. Specifically, CMS states that quality measures:

• Guard against abuses and misuse of healthcare services
• Ensure patient safety
• Reveal areas where interventions might improve care
• Identify how and where service improvements should be made
• Help patients make more informed choices about the care they receive
• Provide objective data for policy discussions about healthcare programs and investments
• Act as a test to see what healthcare processes and techniques work the best, to drive continuous improvement
• Keep healthcare providers and insurance plans accountable for standards of care
• Provide data for comparison when it comes to assessing the quality of health care one can receive from different providers and in different geographic regions.

Despite a rather wide scope of tasks, the key reason for implementing quality measures is to help the US Health Care system drift away from the traditional fee-for-service model and toward payment focused on the value of care.

What are the components of a health care TQM system?

There are several common types of health care quality measures in an overall TQM reporting system. Let’s look at each of them in detail to better understand the composition of US health care assessment.

Structural Measures

Structural measures focus on facilities and their structures. The main idea behind structural measures is to give consumers a sense of a health care provider’s infrastructure, capacity, and the processes carried out within the institution or by a single clinician to provide high-quality care. Examples of attributes tracked within the framework of structural measures include:

• Percent of providers using an electronic health record (EHR) and if the health care provider utilizes a medication order entry system
• Staff-to-patient ratio
• The number of board-certified physicians

Process Measures

Process measures define and measure the steps that need to be taken to provide care. Process measures are aimed at informing health care consumers about the medical care they may expect to receive for a given condition or disease. Examples of attributes tracked within the framework of process measures include:

• The percentage of people receiving preventive services (such as monitoring, screenings, and immunization)
• Use of aspirin or other antithrombotics to treat ischemic diseases
• Percentage of shoulder surgeries versus physical therapy

Outcome Measures (Intermediate)

Outcome measures reflect on the impact health care providers have on the overall health status of their patients. It measures the success rate of the procedures conducted during the health care delivery process and puts a numerical value on the results of it – clinical events, recovery, and health status. The outcome measure comprises both positive and negative outcomes. Examples of attributes tracked within the framework of intermediate outcome measures include:

• The percentage of patients who died because of surgery (surgical mortality rates)
• Diabetes long-term complications admission rate
• The rate of surgical complications or hospital-acquired infections

Patient Satisfaction

Unlike the previous measures that are based on quantifiable information, patient-reported outcomes refer to the data collected from the health care receivers (or their family or caregivers) directly, without any interpretation from the health care organization. This means patients or their representatives give feedback regarding the quality of their personal health care experience and the results of it. Examples of attributes tracked within the framework of patient-reported outcomes include:

• Consumer Assessment of Healthcare Providers and Systems (CAHPS): patient experience
• Gains in patient activation scores (PAM) at 12 months

Resource Use/Cost/Efficiency

Finally, the last type of measure that affects the overall ranking of health care providers is the way they manage the resources available to them. It consists of the cost of care, its accessibility, resources used (people, supplies, etc.) to provide care, as well as measures the frequency of inappropriate use of resources. Examples of attributes tracked within the framework of resource-related measures include:

• Total costs of health care per person
• Avoidance of antibiotics for adults with acute bronchitis

What steps has been made towards a TQM

One of the major challenges of the US health system is that it is made up of independent organizations that often measure quality in a way that is unique to them. To bring some type of standardization, the government and nonprofit agencies have developed the HEDIS, CMS Star Ratings, Core Quality Measures (CQMs), and MACRA quality measures.

HEDIS

HEDIS stands for Healthcare Effectiveness Data and Information Set. HEDIS measures how well a health plan provides service and care to its members. This measurement allows employers and individuals to use HEDIS to compare the quality of health plans (insurers).

Today, according to the National Committee for Quality Assurance (NCQA), over 90% of US health plans rely on the HEDIS measures to compare healthcare performance with other health plans.

“Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an ‘apples-to-apples’ basis,” the NCQA notes. “Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.”

Generally, HEDIS measures are rather granular, with detailed reporting requirements: health care payers are to collect HEDIS measures to report the number of chronic disease screenings providers to administer to patients, as well as to monitor healthcare utilization rates, supplemental health care evaluations, and follow-up appointments for medical and behavioral conditions.

CMS Star Ratings

Medicare uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Medicare scores how well plans perform in several categories, including quality of care and customer service. Ratings range from one to five stars, with five being the highest and one being the lowest.

CMS Star Ratings is a metric specific to the Medicare program, assessing the quality of all the Medicare-sponsored health care plans.

The factors used for the quality assessment within the framework of CMS Star Ratings include:

• If Medicare beneficiaries remain healthy while on their plan
• Management and improvement of beneficiary chronic conditions
• Member experience with health plans
• Customer service performance
• Member complaints with health plans
• Changes in overall health plan performance

MACRA Quality Payment Program (QPP)

MACRA is a law that created a quality payment system for physicians. The Quality Payment Program (QPP) consists of two major tracks: The Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs). Most providers will initially participate through MIPS. The 4 scorable MIPS categories in 2020 are:

• Quality (45% of score)
• Promoting Interoperability (25% of score)
• Improvement Activities (15% of score)
• Cost (15% of score)

MIPS annually scores eligible Medicare Part B clinicians on a 100-point performance scale which results in a Composite Performance Score (CPS). Their payments will adjust based on this score, which is calculated by the measures and categories reported. MIPS rolled three existing quality and value reporting programs (PQRS, VBM, and MU) into one points-based program.

CMS has several alternative models to MIPS. The purpose of this flexibility is to both experiment with better measurement methods, and to understand if certain measures are more applicable to specific physician populations.

Core Quality Measures (CQMs)

The Core Quality Measures are a collaborative initiative of AHIP, CMS, and NQF. They comprise a set of eight performance benchmarks that focus on both general medical care and specialty services.

The Core Quality Measures Collaborative measures patient outcomes within accountable care organizations, patient-centered medical homes, primary care cardiology, gastroenterology, HIV and Hepatitis C care, oncology, obstetrics and gynecology, and orthopedic practices.

What Does This Mean for Patients?

Implementation of quality measurements seeks to improve the overall quality of clinical care and patient experience simultaneously. Its collection and publication increases transparency, tracks inequities in the distribution of care, and moves the system away from fee-for-service to value-based care.

The Japanese have a strategy called Kaizen which is a continuous pursuit of improvement through incrementalism. It becomes part of an organization’s culture. While these initial quality measurements were created with positive intentions, the current state of US healthcare indicates that there are certain gaps associated with our current collection methods.

First, the plurality of different quality assessment metrics leads to an inability to compare healthcare providers efficiently – they could be using a different benchmark to report on the quality of their services. Moreover, even when providers use the same metrics, the evaluation results can still be flawed with inaccuracies – they are heavily dependent on who is surveying and tabulating the results.

Secondly, like any system, particularly in the beginning, there can be manipulation to attain quick wins to improve ranking. Here are some of the examples of the health care distortions that are caused by the quality measurements:

Prioritizing easier care for healthier people: For instance, health care providers can focus on moving a healthy patient’s systolic blood pressure from 141 mm Hg to 139 mm Hg, thereby crossing the 140 mm Hg threshold to get better quality assessment results, rather than help someone with a heart attack history improve from 180 mm Hg to 155 mm Hg.

Over testing: Repeat colon cancer screening too early if the prior test was billed to a prior insurer.

Overmedication: The Medicare National Pneumonia Project ruled out “first antibiotics within 4 hours of hospital arrival” as a national quality measure in 2002. However, on many occasions, the diagnosis of community-acquired pneumonia is often unclear during the initial evaluation. In that case, the appropriate management of a stable patient is often to withhold antibiotics pending a more certain diagnosis. Here a health care provider is faced with a conflict of interest – either to act in accordance with the protocol or to secure better process quality measurement results on paper.

However, by adopting the spirit of Kaizen, and an appreciation that measurement will improve and increase in standardization we can appreciate these short-term issues will eventually be remedied.

The Future of Health Care Quality Measurements

Due to the COVID-19 pandemic, a lot of unrelated viruses research activities have been pushed back. However, on a larger scale, it is still possible to talk about general health care progress trends. The medical community is always on the verge of the next breakthrough in health science, which equates to a promise of more effective health care solutions and, subsequently, a higher health care quality benchmark. It also means that our health systems must continually anticipate and adapt to change.

Importantly, as discussed in our blog article Envisioning a Real-Time Health System, this global health crisis has uncovered the dearth of patient population real-time intelligence and flexible health system structures, further underscoring the need to accelerate a real-time healthcare system (RTHS).

This is where the spirit of Kaizen is so critical as our health systems evolve, therefore future quality measurements must acquire data on an organization’s flexibility and time to respond.

The easiest way to arrange that is to unify and standardize the metrics, discover their gap, improve the system, and repeat.